Paeds Cases · ophthalmology
Visual development, amblyopia and vision screening in childhood — structured clinical encounter
Structured encounter testing the approach to a five-year-old found at school-entry screening to have reduced left eye acuity: the recognition of amblyopia as a cortical deficit, the sensitive period, the classification of amblyopia types, the stepwise management ladder and the Pediatric Eye Disease Investigator Group evidence, with a closing pivot to a two-month-old with leukocoria and an absent red reflex for the urgent deprivation red-flag pathway.
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Station 1 — recognition
Asked for my first impression, I would recognise this as amblyopia. The unilateral reduction in acuity that does not improve with a pinhole, in a structurally normal eye with a symmetric red reflex and no turn, is the signature of a functional cortical deficit. The key teaching is that amblyopia is a brain problem rather than an eye problem: during the sensitive period the cortex suppressed the input from that eye, so the neural machinery for sharp vision never matured, and the eye itself looks entirely normal. [2]
References7ShowHide
- [1]Donahue SP, Nixon CN Visual System Assessment in Infants, Children, and Young Adults by Pediatricians. Pediatrics, 2016.PMID 29756730
- [2]Holmes JM, Clarke MP Amblyopia. Lancet, 2006.PMID 16631913
- [4]Wallace DK, Edwards AR, Cotter SA, et al. A randomized trial to evaluate 2 hours of daily patching for strabismic and anisometropic amblyopia in children. Ophthalmology, 2006.PMID 16751033
- [5]Repka MX, Kraker RT, Holmes JM, et al. Atropine vs patching for treatment of moderate amblyopia: follow-up at 15 years of age of a randomized clinical trial. JAMA Ophthalmol, 2014.PMID 24789375
- [7]Solebo AL, Cumberland PM, Rahi JS Whole-population vision screening in children aged 4-5 years to detect amblyopia. Lancet, 2015.PMID 25499167
- [10]Anderson J Don't Miss This! Red Flags in the Pediatric Eye Examination: Abnormal Red Reflex. J Binocul Vis Ocul Motil, 2019.PMID 31329054
- [11]Gopal SKS, Kelkar J, Kelkar A Simplified updates on the pathophysiology and recent developments in the treatment of amblyopia: A review. Indian J Ophthalmol, 2019.PMID 31436180